When a patient comes to the dermatologist's office seeking to reduce age-related changes on the face, the specialist must objectively inform him about the different methods of correction – both cosmetic and surgical - and about the possible effects of exposure. Often patients do not want to hear about surgery and prefer conservative methods. But there is no doubt the need for cooperation between surgeons and dermatocosmetologists both in the complex treatment of problems of an aged person, and in the period of preoperative preparation, postoperative rehabilitation of the patient.
However, some issues of such interaction cause disagreement among specialists.
The greatest number of disagreements occurs when discussing the following fundamental issues:
What is meant by aesthetic deformation, and at what degree of its severity does it need to be corrected?
What are the best ways to correct the deformity that will lead to a more or less long-lasting aesthetic effect?
Which is preferable – elimination of the existing deformation or its temporary camouflage?
And, finally, who sets the task and determines the scope of the forthcoming intervention: the doctor or the patient? Does the doctor tell the patient about all the deformities he has and, accordingly, the possibilities for their elimination, or does he focus only on those deformities, the methods of correcting which he knows?
Participating in the discussion:
- Sergey NUDELMAN, plastic surgeon, director of the Center for Cosmetology and Plastic Surgery (Yekaterinburg);
- Irina ZHUKOVA, Candidate of Medical Sciences, General Director of the medical and cosmetic center "Kosmed" (Moscow);
- Tatiana ILESHINA, PhD, dermatocosmetologist of the beauty salon "Veronika" (Moscow);
- Elena GUBANOVA, Candidate of Medical Sciences, dermatocosmetologist, leading specialist in injection techniques of the Vallex M company; (Moscow).
What is meant by aesthetic deformation, and at what degree of its severity does it need to be corrected?
Of course, aesthetic deformation should be understood only as something that does not suit the patient himself. The doctor's opinion is completely irrelevant. The need for correction depends only on the will and desire of the patient himself.
What are the best ways to eliminate the deformity, which will lead to a more or less long-term aesthetic effect. What is preferable – elimination of the existing deformation or its temporary camouflage?
Preferably, only what the patient himself prefers, who, of course, received all the necessary objective information from several unrelated doctors. This leads to the answer to the first part of the question. The degree of optimality is also determined by an informed patient. In doing so, the doctor must act as an independent adviser.
And, finally, who sets the task and determines the scope of the forthcoming intervention: the doctor or the patient? Does the doctor tell the patient about all the deformities he has and, accordingly, the possibilities for their elimination, or does he focus only on those deformities, the methods of correcting which he knows?
Based on the foregoing, it becomes clear that in setting the task and determining the scope of the intervention, the priority decision is the decision of the patient. And only him. The independent opinion of the doctor (if possible) should be dictated by considerations of maximum non-traumatic for the patient, which, of course, should not reach the point of absurdity. For example, if the doctor sees that the result is achievable only with rhytidectomy, and the patient insists on superficial peeling, the only way out of this situation is to unambiguously refuse this patient.
S. Nudelman. Everyone chooses their own path in surgery. I am sure that it is the doctor who should be the guide for the patient, and not vice versa. Duty of a doctor – convey to the patient in the most accessible form information about the upcoming actions to correct deformities and convince him of the reasonableness of his own approach. There are the wishes of the patient, and there is the reputation of the doctor.
If a doctor is confident in the correctness of his decisions, he has no right to be guided only by the wishes of the patient and, from his point of view, go along a deliberately false path. The position of the doctor and his approaches, no doubt, determine the circle of those patients with whom he works. Patients are very sensitive to the position of the doctor. Some like the fact that they have the opportunity to use a specialist to solve the problems they set themselves, although, as a rule, the knowledge of such patients is limited to articles from glossy magazines.
Another part of patients expect competent recommendations from the doctor, expressing only wishes about those deformities that most disturb them and create complexes that prevent them from feeling confident. To give everything at the mercy of the patient – quite a comfortable position for some doctors. In case of failure, you can always refer to the fact that “we were ordered – we did it, you yourself wanted it. The qualification of a doctor is largely determined by his ability to convey his beliefs to the patient. Denial of treatment or loss of a patient after a consultation means a defect in work.
The difference in approaches determines the difference in positions, and, as we see, not only between cosmetologists and surgeons, but also within each of these specialties. On the other hand, the objective need to proceed from the interests of the patient forces us to seek reasonable compromises.
Just reasonable compromises, not mercantile conformism. Such behavior does not imply a rejection of one's own principles, but only their meaningful change, primarily in the direction of involving doctors of various specialties in joint work with the patient, which makes it possible to justify the most daring expectations of patients and satisfy their own aesthetic ambitions. That is why such a discussion is interesting and useful for both cosmetologists and surgeons.
Let's try with the help of the presented photos, based on the real information they carry, to formulate this unified approach to the aesthetic correction of an aged face.
Patient #1
S. Nudelman. Patient 1 with fairly pronounced age-related tissue changes, mainly in the middle and lower thirds of the face and neck.
In the upper third of the face – asymmetry in the position of the eyebrows, the left palpebral fissure tends to be somewhat more round than the almond-shaped right one. There is a slight hypertonicity m. corrugator and m. procerus, which led to the formation of visible static wrinkles in the bridge of the nose. Due to a decrease in skin elasticity, there is a slight influx in the area of the outer corner of the left eye, this is also aggravated by the lower standing of the left eyebrow.
In the middle zone of the face there is a pronounced flattening of the malar zone due to the downward displacement of the soft tissues. This changes the oval of the face, bringing it closer to a more trapezoidal shape.
In the infraorbital region, the nasolacrimal groove is marked, there is also a downward displacement of the border between the lower eyelid and the cheek and, in connection with this, an elongation of the lower eyelid. The corners of the mouth are somewhat lowered and go into the "puppet fold". The upper lip is somewhat flattened due to atrophy of subcutaneous fat in the lip area and partial atrophy of the alveolar process in the upper jaw.
The red border of the upper lip is thin, with loss of volume. The line of the lower jaw and, accordingly, the oval of the face are deformed and indistinct. In the neck area, there is a pronounced deformation of the platysma, there is a divergence of its medial edges, hypertonicity in the vertical direction and a decrease in tone – in horizontal. Due to this, deforming musculoskeletal strands are formed over the entire area of \u200b\u200bdistribution of the muscle.
The patient also noted a decrease in elasticity and optical transparency of the skin, the presence of a network of relief static and superficial wrinkles caused by photoaging of the skin.
If the patient was determined to actually eliminate the existing age-related deformities, the following could be offered to her:
- in the upper area of the face – endoscopic forehead lifting with predominant movement of tissues in the area of the outer section of the left eyebrow with the simultaneous elimination of hypercorrection m. corrugator, m. procerus, m. frontalis. It is also necessary to perform upper blepharoplasty with minimal removal of subcutaneous fat in order to eliminate the effect of "sunken eyes". in future. Additionally, it would be possible to perform canthofixation on the right and canthopexy on the left, which would make it possible to align the position of the outer cantuses and prevent their lowering in the future;
- in the middle zone of the face – lower blepharoplasty with a minimum skin excision of no more than 1–2 mm. In order to eliminate the nasolacrimal groove – subperiosteal detachment of a block of tissues in the malar area with their subsequent movement laterally upwards with fixation to the periosteum of the orbit in the region of the lateral canthus.
This will smooth the nasolacrimal sulcus, strengthen the preseptal and pretarsal portion of m. orbicularis oculi, giving it an additional point of support, and to shorten vertically the visible omission of the border between the lower eyelid and the cheek. Further – SMAS-rhytidoplasty for the formation of the oval of the face, elimination of nasolabial folds and "puppet folds" and stabilization of the corners of the mouth.
In order to create additional volume – plication of the detached SMAS above the zygomatic arch. Transfer of the anterior SMAS flap to the postauricular region with fixation of this flap in tension.
The whole complex of surgical interventions will make it possible to create a good face oval with an increase in volume in the malar region and its decrease in the buccal region.
In the neck area, the effect can be achieved mainly by platysmaplasty. It is necessary to perform a medial platysmaplasty with suturing the medial edges of the platysma and conducting a medial platysmotomy. Open or closed lipectomy in the submandibular region. If necessary – corset plication of platysma to eliminate ptosis of the submandibular salivary glands.
Lateral platysmaplasty and platysmotomy are also required. All the measures described earlier will lead to the restoration of the oval of the face and help to form the correct neck-chin angle close to 90°; and eliminate static and dynamic deformations of the platysma.
To improve the strength and aesthetic characteristics of the skin, I would recommend finishing the operation with one of the types of peeling, for example, an erbium laser. Lipofilling is necessary to eliminate skin deformation in the area of the upper lip. In the postoperative period, the optimal procedures will be: mesotherapy, massage, lymphatic drainage and other rehabilitation measures by a cosmetologist-rehabilitologist.
If the patient is in the postmenopausal period, a consultation with a gynecologist and endocrinologist is necessary for the possible appointment of hormone replacement therapy.
In the late postoperative period – obligatory observation by a cosmetologist and a specialist in anti-ageing therapy. It is important not only to achieve an aesthetic result, but also to keep it as long as possible.
Patient 1 – an ideal candidate for lifting, there is a phenomenon of skin ptosis. With a high degree of obtaining a very effective result, it can also be operated on by a novice plastic surgeon. In this case, I would recommend a neatly executed conventional skin lift. The need for platysmaplasty can only be clarified during the operation – with such a hyposthenic type of skin constitution, platysma may turn out to be thin and inelastic, which makes manipulations with it undesirable; in addition, the correct traction of the skin is quite capable of "pressing down" platysma. The impoverishment of the middle third of the face will be replenished with redistributed skin, although plication of the subcutaneous layers in this area may also be required. Naturally, plastic surgery of the upper eyelids will not be superfluous.
I. Zhukov.
Patient 1 indeed shows significant signs of age-related changes – wrinkles of the periorbital and perioral regions, soft tissue ptosis, as well as deformity of the neck and facial contours. I fully agree with my fellow surgeons that in this situation, optimal aesthetic results can only be achieved with complex treatment.
A combination of operative lifting, blepharoplasty, chemical peeling at the middle level and contouring of the middle zone of the face with hyaluronic acid preparations is shown. In the future – skin revitalization by mesotherapy methods (Placentex, x-AND, vitamins, microelements, vascular agents).
E. Gubanova. I am very impressed with the approach of I. Zhukova. The only thing is that I would still prepare the skin for plastic surgery, that is, I would conduct a preliminary course of rejuvenation.
Of course, my first question is: how do you feel about plastic surgery? If the patient is motivated, in my opinion, the following sequence of stages of rejuvenation is ideal in her case: TCA peels, then mesotherapy with fibroblasts, hyaluronic acid, vitamins and microelements, active cellular cosmetics and moisturizing procedures.
Further, the second stage should be plastic surgery, the third stage – rehabilitation (physiotherapy), at the fourth final stage, after the removal of edema, – botulinum toxin injections in the upper third of the face and neck. Alternative options can also be offered. A patient should always have a choice!
Option #2:
- skin rejuvenation course is the same;
- surgery plus laser exposure immediately or after 3–6 months– dermabrasion;
- botulinum toxin and contouring with hyaluronic acid (HHA) gels.
Option #3:
- phenol peel or dermabrasion;
- botulinum toxin and GHA contouring;
- plastic surgery, if the patient is not satisfied with the "new facial tone".
Only conservative techniques without deep peels will give only a superficial effect of skin rejuvenation.
T. Ileshina. For patient 1, I would have performed several medium or medium-deep peels of the skin of the face and neck with a combination of TCA and high concentrations of glycolic acids, possibly – deep peeling of the area around the mouth. Laser resurfacing of facial skin using an erbium laser is not excluded. Further or in the intervals between peelings – a course of mesotherapy with revitalizing preparations (Ial-system, fetal preparations).
In the course of mesotherapy, it is necessary to introduce lipolytic cocktails for the face in order to eliminate fatty lumps in the cheekbones. The introduction of fillers will help to add volume to the upper lip. Fillers are also desirable to be introduced into the nasolabial folds. It is necessary to treat the platysma with a botulinum toxin preparation, it is also good to use it in the nose and forehead to level wrinkles.
Patient #2
I. Zhukov. Now it would be interesting to hear the opinion of surgeons and cosmetologists regarding the patient presented in photo 2.
E. Gubanova. It seems that this patient has already had plastic surgery or she has a good heredity. I would give her 45 years. There are signs of photoaging and mimic wrinkles of the upper third of the face. My suggestions are:
- work with the skin with median peels, perform chemical blepharoplasty (phenol) in the absence of a permanent photosensitizing factor;
- combination of mesotherapy with hardware cosmetology and care with whitening procedures;
- injection of botulinum toxin into the area of the upper third of the face and contouring of the HGC;
- upper eyelid blepharoplasty.
In my opinion, there are no indications for circumferential plastic surgery.
I. Zhukova. Patient 2 has predominantly expressed mimic wrinkles of the forehead and periorbital area, as well as phenomena of uneven pigmentation of the skin of the face. I agree with E. Gubanova that, first of all, a course of peeling procedures of the middle level of exposure is necessary, in the future – blepharoplasty. Revitalizing mesotherapy and cosmetics are also shown in combination with hardware methods of influence (microcurrent stimulation, ultrasonic phonophoresis).
T. Ileshina. This patient undoubtedly needs peeling therapy, but for her I would choose retinoic and glycolic peels. A course of post-peeling mesotherapy with revitalizing preparations, treatment of deep wrinkles around the eyes and on the forehead with mesotherapeutic techniques using gel preparations after correction of this area with Botox. The introduction of fillers into the lips and nasolabial folds.
Analysis of the condition of patient 2 is very difficult. Most likely, in the recent past, she has already undergone facial plastic surgery in one modification or another, and with a very good result. The dominant aesthetic disadvantage in this case is the pronounced involutional changes in the orbital regions. Upper blepharoplasty will give a very good result, and the brow lift is completely in vain.
Radial wrinkles in the lower eyelids in this case are a difficult problem to solve, since, judging by the skin's tendency to hyperpigmentation, both laser resurfacing and chemical peels are absolutely contraindicated here. One might consider mechanical dermabrasion, since the latter still causes less pigmentation, although with this type of skin it is very likely to get a noticeable atrophy or a pronounced line of demarcation. So I would advise you to limit yourself to the botulinum toxin preparation.
Patient #3
I. Zhukova. Patient 3 has pronounced age-related changes. Ptosis of soft tissues prevails with a significant subcutaneous fat layer, especially – in the area of the cheeks with deformity of the oval of the face. In addition, mimic wrinkles of the periorbital region and the middle zone of the face are sharply marked – bridge of the nose, nasolabial folds and corners of the mouth. Complex treatment is shown – blepharoplasty plus "Botox" in the eye area, face lifting in combination with contouring of the middle zone. At the end – medium peeling and active cosmetic care.
E. Gubanova. I do not quite agree with the sequence proposed by I. Zhukova. Patient 3 – a woman over 60 with a variant of "fatty facial aging".
First stage – invite her to try to lose 5 kg.
Second stage – circular plasty with blepharoplasty.
Third stage – dermabrasion.
Fourth stage – botulinum toxin and contouring of the remaining wrinkles and folds of the HGC, into destructured lips – permanent or solid implant.
Fifth stage – maintaining the effect by mesotherapy methods, superficial peels, hardware techniques, cellular cosmetics care.
Botulinum toxin and contouring will not remove static deep facial wrinkles, therefore, in my opinion, dermabrasion, and not laser exposure, will be the ideal method for rejuvenating this kind of thick skin.
T. Ileshina. In my opinion, the case of patient 3 is the most difficult for a dermatocosmetologist. She hardly ever resorted to aggressive interventions, and the correction of involutional changes in the face of this patient will require significant time and material costs, and the results may not be satisfactory for her. At the beginning, it is necessary to carry out the treatment with medium-deep peels, supplementing them with deep peels of the areas around the mouth and around the eyes.
In the course of post-peeling therapy with revitalizing preparations, it is necessary to include lipolytic cocktails and inject them into the area of the cheeks, cheekbones and double chin, as well as gel preparations – for the treatment of wrinkles remaining after peeling in the area of the eyes and mouth. It is recommended to prescribe Botox injections. in the area of the nose and eyes, the introduction of fillers into the lips, tattooing of the eyebrows.
Indeed, patient 3 is the most difficult case and therefore it would be best to reject her altogether. The difficulty is due to a combination of the following: a thick, round face with a short (most likely, since this is not visible in the picture) neck, generalized subcutaneous hypertrophy, and a finely wrinkled type of skin wilting. I'm afraid most doctors will offer her a deep rhytidectomy plus laser resurfacing of her entire face. In my opinion, in this case, she will not receive a rejuvenating effect.
Therefore, the most important part of – this is a pre-op discussion. It is necessary to form the right level of expectations. With the adequacy of the patient and her perseverance, I would limit myself to plastic surgery of the upper eyelids plus brow-lift, plastic surgery of the lower eyelids with any remodeling manipulations on the lacrimal grooves, mini-lifting in order to restore only the correct parabola of the oval and local liposuction of certain areas of the face.
All this is much easier to bear than, for example, composite rhytidectomy, and the result will be the same, if not better. With the patient's continued desire for surgery (of which I am not very sure), the second stage could be laser resurfacing of the entire face. But, I repeat, the end result is unlikely to satisfy both the doctor and the patient.
Patient #4
I. Zhukova. In patient 4, age-related changes are moderately expressed, there are initial manifestations of soft tissue ptosis with the formation of a "tired face". In this case, it is possible to achieve good aesthetic results when using a course of glycol peeling in combination with mesolifting, which, if necessary, can be supplemented with contouring with hyaluronic acid preparations. Active cosmetic anti-ageing procedures are also indicated to maintain the achieved results.
E. Gubanova. I do not agree with the first part. In this case, it is indeed possible to achieve good, but, unfortunately, temporary results without surgical plastic surgery. If we want to achieve a long-term result, and patient 4 is ready for surgery, then, of course, blepharoplasty and a circular lift in combination with liposuction of the chin will help we can achieve it.
Next – everything else: botulinum toxin, GHA contouring, superficial or median peels (glycol, TCA), laser, to maintain the effect – mesotherapy. Care – active cellular cosmetics.
T. Ileshina. For patient 4, I would suggest photorejuvenation of the facial skin or a course of median peels in combination with mesotherapy. In the course of mesotherapy, it is necessary to include lipolytic cocktails for the lower third of the face and the correction of a double chin. The drug "Botox" it is desirable to treat the area "between the eyebrows". I rarely correct involutional changes in the face without prescribing certain corrective drugs that optimize the recovery period and significantly enhance all ongoing procedures. In addition, the patient should be consulted by a gynecologist-endocrinologist for the possible appointment of hormone replacement therapy.
The improvement in the appearance of patient 4, in my opinion, is quite achievable with the help of upper eyelid surgery, lower eyelid surgery with obligatory canthopexy (ciliary weakness can be assumed) and liposuction of the entire submental zone.
S. Nudelman. In my opinion, all of the presented patients need some degree of surgical correction, which should be supplemented by the final dermatological cut. None of the presented patients can achieve a full aesthetic result using only a mono-surgical or cosmetic approach. One can only argue about the degree or legitimacy of this or that applied method.
T. Ileshina. In conclusion, I would like to say that I am sure that plastic surgery would significantly improve the appearance of the patients presented for discussion, but, as a dermatocosmetologist, I proceed from the assumption that the operation is not indicated for them for some reason.
Summarizing my impressions, I can say that in general I agree with the opinion of all dermatologists-cosmetologists, especially since they did not say anything new for the simple reason that it is impossible to say anything new and something fundamentally unusual. But why are the following very important points passed over in silence:
- the material side of the issue. After all, the programs offered by cosmetologists can result in absolutely fabulous sums;
- treatment cycle duration – from start to full recovery. The cosmetologists' suggestions suggest that patients have an infinite amount of free time and patience, and they are ready to make caring for improving their appearance (with very modest results, for example, in patient 3) their main profession. But our patients – These are real people, not dolls. And this is exactly what, in my opinion, is completely forgotten;
- somatic status. Nobody talks about it, although, for example, the proposed phenol peeling requires excellent health from patients.
Now, as for the opinions of surgeons, in general I think that S. Nudelman's proposals are unnecessarily traumatic.
I. Zhukova. Analyzing all the recommendations on possible ways of surgical and cosmetic methods of "rejuvenation" proposed patients, as well as based on the practical experience of many years of observation of both operated patients and those who preferred conservative treatment, in my opinion, the following conclusions can be drawn.
Undoubtedly, plastic surgery allows you to perform real “miracles” and nothing can compare with it in terms of the ability to achieve aesthetic results.
Cosmetological methods of influence very well complement surgical operations. This, among other things, is evidenced by the fact that many surgeons themselves actively use various types of peelings, contouring, etc. in their work.
We must not forget about the large number of patients who do not want and will never have plastic surgery. Therefore, cosmetic methods of rejuvenation are very relevant and will continue to improve. In my opinion, it is incorrect to pose the question – which is more effective, since it is an attempt to compare incomparable things, which cannot bring results. Our task – unite the efforts of surgeons and cosmetologists as much as possible in the interests of both patients and doctors.
E. Gubanova. It is very important to offer our patients non-surgical methods of treatment, while in no way detracting from the dignity of plastic surgery, and sometimes supplementing it. These two independent regions cannot be identified, but they must be friendly. I wish us mutual understanding, development of highly professional relationships for the benefit of patients, improvement of existing and application of new technologies.
S. Nudelman. There is no doubt that the same aesthetic result can be approached using different methods. It is also necessary to keep in mind the objective "limiters": the material factor, the general state of the patient's health, the degree of professional competence of the doctor, the patient's confidence in the degree of discomfort he is ready to go to in order to achieve the result, and also how convincingly and understandably the person working with with him, the doctor formulated what aesthetic result he was striving for.
The last argument is of fundamental importance. The patient should not be deprived of the right to receive the most complete information about all available methods that can be used to achieve the maximum result in the elimination of congenital or acquired aesthetic deformities while respecting the preservation of facial features. In practice, as a rule, the proposed set of services for the correction of deformities is limited to those methods that the doctor working with patients knows.
Obviously, it is impossible to achieve a result using only known mono-approaches. Only comprehensive solutions to eliminate existing deformations (in different ways and at different levels of impact) can lead to the planned goal. At the same time, it is not so important that the basis of the ideology of cosmetologists is the camouflage of deformity, while the surgical position provides for its elimination. I am sure that the difference in positions within each specialty cannot interfere with joint work, in each specific case there is a field for many methods.
Surgeons, performing aesthetic restoration of the face, cannot achieve satisfactory results on skin with pronounced signs of elastosis, rosacea, superficial rhytides and other manifestations. Without a doubt, any surgical correction should be accompanied by the participation of a beautician at the pre- or postoperative stage, just as the work of a beautician involves the natural transfer of the patient to the surgeon to eliminate problems that cannot be solved with conservative methods. P
In this case, the desire of the patient after the surgical stage to return to the cosmetologist again in order to preserve and maintain the result achieved with the help of surgery is quite understandable and understandable. There is also no doubt that there is a problem of gaps in understanding the possibilities of those methods and techniques that alternative specialists possess. The issue of awareness of the achievements of aesthetic medicine becomes fundamental.
Ignorance breeds craftiness in the profession, when the intended effect is declared, but not achieved. Often the main efforts of the doctor are directed not to the analysis of failures, but to the patient's conviction that the planned result has been obtained.
When starting to work with a patient, it is necessary to explain to him the cause of the deformity, give a list of all possible ways to eliminate it and the risks associated with this elimination. An informed patient can make a decision and be an ally of the doctor both in the upcoming process of restoring and improving lost traits, and in case of any problems.
The main task of any specialist is not only to achieve the result, it is equally important to keep it as long as possible. Patients who are in the period of pre- or menopause should be consulted by a gynecologist-endocrinologist and receive the necessary recommendations. This will help to provide biological support and long-term aesthetic results.
Complex intervention based on knowledge and the desire to involve different specialists to solve the problem set by the patient can give an optimal aesthetic result that will meet the patient's wildest expectations and realize the doctor's professional ambitions.
According to the materials of the site www.russiansam.ru
Share:
Add a comment